EMDR Therapy Quarterly

If ever there was a time to think about resilience it is now. Two years on from the worst part of the pandemic, four months on from the start of the current episode of the Russia/Ukraine war, we are facing increasing costs of living, stagnant wages, reduced capacity in our NHS for mental and physical health, and an ever-widening gap between rich and poor. Every day in our practice we are seeing clients whose resilience capacity is at an all-time low; and we, as practitioners, are not immune.

It is appropriate then that The EMDR Europe Association took as its theme for the annual conference this year ‘EMDR and Resilience’. Each of the three keynote speakers addressed resilience from a slightly different perspective and, taken together, their conclusions highlight that EMDR therapy has much to offer in terms of increasing our clients’ resilience.
Neurobiology was the focus for the Friday keynote speech given by Dr Christiaan Vinkers from Amsterdam University Medical Centers. He addressed the integration of psychological and biological determinants of stress and trauma and proposed that they might provide a novel road for new interventions.

Whilst stress is popularly considered to be a bad thing, this is not necessarily the case. Dr Vinkers pointed out that traumatic stress is mainly adaptive. It has its effects at different levels in the body (i.e., neuronal/molecular, cellular/blood, neuroendocrine, autonomic nervous system (ANS), immune system, brain networks and cognition/psychology), not just on behaviour. He stated “Conceptualising stress at all of these levels and including environmental and contextual factors can help to explain the large interindividual differences in resilience that we regularly observe in our clients”.

The concept of ‘stress dynamics’ can help us to understand what is going on in the body. The normal healthy response to stress consists of an acute phase and a recovery phase. Firstly, the acute phase is about appraisal and coping; this is dependent upon previous experiences, expectations, and context. Cortisol is released in this phase (along with [nor]adrenaline). After the stressor has gone, we must learn from the stress and adapt to it and the stress response has to be shut dow n to prevent our bodies entering a chronic state of stress activation. In the adaptation/recovery phase the effects of cortisol (that continue to increase and remain high for some hours) are mediated through the glucocorticoid receptors in the brain. (This is important to know as activation of the GC receptors can be measured and they can be a target for pharmacotherapy). The effects are noticed at the cellular, brain network and behavioural levels. The brain flips between different networks in healthy individuals but gets stuck in certain networks in response to trauma, such as in reward processing and emotion processing.

Translating this concept to childhood trauma (CT) brings with it an understanding about consequent psychopathology. About 25% of adults with depression reveal a history of CT. Around half of childhood-onset psychiatric disorders and one third of all psychiatric disorders are related to CT. It seems that such individuals have more severe and recurrent symptoms. (Nanni, Uher & Danese, 2012). . CT disrupts the development of the stress system due to high cortisol levels. This impairs stress system dynamics, increases stress sensitivity and reduces resilience across the life span; however, it also offers an opportunity for intervention.

Dr Vinkers explained how the three stress response markers (ANS, immune system and HPA-axis)
are all influenced by CT, and this causes changes in brain structure and function, development of personality characteristics and cognitive function. It also directly influences biological aging and somatic health. Adults who experienced CT are more likely to develop metabolic syndrome, obesity and mental illness and, ultimately, to die younger. An interesting fact is that CT inhibits the development of the white matter tracts (that affect learning and other brain functions) in the brain and this under-development is consistently seen in patients with type I bipolar disorder, suggesting that this disorder may be a stress response.

Epigenetics (the modification of gene expression) crops up everywhere and the influence of CT on DNA methylation (that changes the activity of a DNA segment in the gene) is pronounced, making it more difficult for DNA to translate to RNA. One particular gene is affected (KITLG) and this affects an individual’s ability to respond appropriately to stress. There is therefore, a
direct link between trauma exposure, PTSD and DNA methylation, which then begs the question….is there scope for reversal of DNA methylation following treatment of PTSD? The answer is yes!

In a 2019 study by Vinkers et al., 44 deployed soldiers with PTSD were given psychotherapy (TF-CBT or EMDR) and 23 deployed soldiers with no PTSD acted as trauma-exposed controls. In all participants, DNA methylation increased in response to trauma exposure as expected. Following treatment, where symptoms decreased there was a reversal in DNA methylation, demonstrating that there are biological correlates for symptomatic improvement. Vinkers thought this intriguing but not surprising. After all, given how trauma affects the body at so many levels, why would a psychological intervention not have any effects on the brain ?

Vinkers went on to argue that childhood trauma is a major public health problem and arguably the most potent predictor of poor mental health across the life span – one third of all psychiatric disorders are related to CT – (Nanni et al., 2012). Rather than just approaching mental health disorders from a clinical perspective we can augment positive outcomes by approaching them from a neurobiological perspective too. He thinks that rather than focusing on static stress changes, stress dynamics may be key to understanding the lifelong vulnerability following childhood trauma. Similarly, an understanding of the biological processes (at the level of (epi)genetics, that underlie responses to stress and trauma) may help to identify those who are at risk, reveal how resilience is shaped and how (biological and psychological) treatments work . Vinkers shared some pre-clinical research that suggests this is the case and that blocking the GR pharmacologically can reverse the effects of early life stress (Arp et al., 2016; Loi et al., 2017).

Most relevant to us as EMDR therapists is that this early work confirms what we already know; that childhood trauma may be specifically targeted independent of diagnosis and that therefore EMDR can have a scientifically valid role in transdiagnostic trauma and stress approaches.

The biological underpinnings of resilience were revisited through Dr Ignacio (Nacho) Jarero’s keynote speech where he talked about the adaptive information processing (AIP) model and the expansion of human resilience understanding. Again, the emphasis was on understanding resilience as a dynamic function at many levels from the biological to the social and environmental. With this in mind, he encouraged us to consider what intervention strategies would most optimally minimise the adverse effects of trauma. In order to do this, we as practitioners need to have an understanding of stress biology and how the body adapts through change (a process known as allostasis).

With respect to the AIP, it is apparent that the physiological memory networks interact to produce psychopathology because pathogenic (dysfunctionally stored) memories are stored in isolation and are unable to connect to adaptive memory networks. This happens when an individual who has suffered trauma is unable to deactivate the stress response when the stressor has subsided or is unable to activate a stress response at all. In a personal communication following the conference, Dr Jarero was keen to stress that, “As of today, there is not enough empirical evidence supporting the effectiveness of EMDR therapy in increasing resilience as defined by the America Psychological Association (APA) after a traumatic event or adverse experience with clinically significant PTSD symptoms.
[This is] because the vast majority of EMDR therapy research with populations showing PTSD or Post-traumatic Stress symptoms infer increased resilience as a by-product of the therapy, but do not have a pre/post follow-up assessment using instruments with international and cross-cultural validity”. More research is required in this area.
The final speaker was Deborah Korn. To illustrate her view on resilience, Dr Korn quoted Nelson Mandela “Do not judge me by my successes, judge me by how many times I fell down and got back up again.” She went on to talk about Eileen Russell’s (2015) idea of resilience as both a potential and a capacity. Resilience potential being the innate capacity to act on one’s own behalf – to strive and adapt to heal from intrusive, dysregulating and traumatic experiences. In EMDR, it is the positive cognition (PC) that represents a person’s resilience potential. Korn’s belief is that as psychotherapists we need to believe in, look for and appreciate this innate resilience potential to effectively guide and conduct therapy with our clients. Resilience capacity is how potential is actualised at any moment in time. It might be emotional, physical, or spiritual and it is contextual. Individuals are not necessarily resilient in all areas of their lives. Some may show resilience in their workplace but come home and totally lack the capacity to thrive in their domestic environment.
As therapists working with complex trauma clients, our aim should be to foster resilience at all stages of therapy. It begins with symptom reduction but involves much more than that. Using the idea of “Rs of resiliency building”, Korn talked about firstly reducing fears. These might be fears of the therapy process itself, of attachment and attachment loss, of inner experiences, of asking for help, of showing vulnerability, or of experiencing change. More complex clients might also fear dissociative parts of the personality. We should consider targeting phobias, fears and ‘urges to avoid’ first, before targeting specific trauma memories. At the same time, reinforce safety by offering psychoeducation, context, skills and relational reassurance. Resourcing is next. Access resources, prioritise the positive and privilege the new. Grab whatever positive appears and reinforce it using bilateral stimulation or dual attention. Develop both positive and negative affect tolerance and importantly “partner with your client’s ‘self as best’ before accessing memories that represent ‘self as worst’”.
Reprocessing and resolving PTSD symptoms, paying attention to focus on easily accessible memories first. During this phase use imaginative interweaves that, amongst other things, assist in developing absent relational aspects and in providing new information for developmental repair.
Fostering resilience, according to Dr Korn, also hinges on developing relationships by constantly striving to undo a client’s aloneness by offering explicit recognition and being receptive and respectful. An aspect of therapy that may be overlooked is self-regulation. If we as therapists are not able to self-regulate, our clients’ ‘neuroception’ will detect our dysregulation and hit the brakes . Use moment-to-moment interweaves to help the client regulate rather than going to a safe place and keep the process moving. Releasing truncated actions is often necessary to re-establish adaptive, active defences in clients who present with chronically activated states of freeze and collapse. We should be looking for opportunities to facilitate developmental repair – perhaps inviting connection between the adult self and child parts to address unmet longings and needs. Reprocessing and then meta-processing give our clients the opportunity for reflection on their experience in order to facilitate the integration of new perspectives and sense of self. The final Rs are standard fare for EMDR therapists: revisit the past and rehearse for the future. As with the other ‘Rs’ these are not necessarily sequential, and especially, working on the present and future should be purposefully attended to in every session.
The essence of this keynote was very much that we should approach each session with our complex PTSD clients by actively seeking out their resilience potential and building their resilience capacity using the ‘Rs’ to guide us. Always making our interventions Relational and experiential and drawing on neurobiology to inform them.
It would seem from these three keynote speeches that how resilience is conceptualised needs to change. So often resilience is talked about as if it is a ‘thing’ that not every individual has, and that the given amount is present at birth and does not change. By thinking about resilience as both a potential and a capacity we can better help our clients. Resilience potential does have pre-natal determinant s, but it is possible to help a client to adjust their stress response and develop their resilience capacity. In doing so, resilience becomes something we do, rather than something we have and we as therapists can compassionately encourage this quality in our clients.